If I do not enroll by my enrollment deadline, what coverage will I have?

If you are a new hire and you do not enroll by your enrollment deadline, you will have the following coverage by default:

Basic Life and AD&D insurance

Short-Term Disability Coverage

Long-Term Disability Coverage

Basic Medical Plan for yourself only with after-tax deductions for your portion of the cost of this coverage. This coverage will remain in effect for the rest of the calendar year. You cannot choose new options during the year unless you have a qualifying change in status.

What about emergency room care?

If your condition is a true emergency, you will have a $100 copayment for emergency services. This is in addition to your deductible and coinsurance for the medical plan option you select.

If you utilize the emergency room for a non-emergency condition, you will have a $300 copayment in addition to your deductible and coinsurance for the medical plan option you select.

For True Medical Emergencies:

Medical Emergency and Emergency Accident facility charges are covered at the HSHS benefit level, whether you go to an HSHS or another facility, regardless of whether that facility participates in the Aetna Other network.

Likewise, Medical Emergency and Emergency Accident Specialist Physician charges are covered at the HSHS Specialist Physician benefit level, regardless of whether the Specialist is an HSHS Preferred Specialist or participates in the Aetna Other network.

Medical Emergency and Emergency Accident PCP Physician charges are covered at the HSHS/Aetna Specialist Physician benefit level, if the PCP is an Aetna Network PCP or an Out-of-Network PCP.

The benefits provided by the HSHS Healthy Plan differ based on whether you obtain services from an HSHS Preferred provider, an Aetna Supplemental provider, an Other Aetna Network provider or an out-of-network provider.

The Plan’s benefits also differ depending on whether the service is provided and billed as a facility service or as a professional service.

Examples of Typical Facility and Professional Services

Inpatient hospital stay for surgery

Facility - Typically, the hospital (facility) will bill for room and board for the days you stay in the hospital, the operating room, the anesthesia you receive (but not the anesthesiologist’s services), any prescription drugs you receive while in the hospital, any supplies used for your care, blood tests and other lab work plus any imaging services, like x-rays or CAT scans you may have while in the hospital. All of these services are usually billed as facility services.

Professional - Physicians’ fees for your surgery, administration of anesthesia, consultations while you are in the hospital, or to read imaging results or analyze tissue samples are usually billed as professional services.

Outpatient surgery

Facility - The hospital or ambulatory surgical center will bill for the operating room, the anesthesia you receive, any supplies used for your care, blood tests and other lab work and any imaging services you receive. All of these services are usually billed as facility services.

Professional - Physicians’ fees for your surgery, administration of anesthesia, or to read imaging results or analyze tissue samples are usually billed as professional services.

Physician’s office visit
The majority of services that occur in a physician’s office are billed as professional services. These include the office visit itself, removal of lesions, biopsies and other procedures performed by your physician.

The exceptions are lab work, like blood tests, and strep tests which may be billed by your physician as professional services but often are billed as facility services by another party. Some physicians utilize providers like LabCorp, Quest or a hospital lab for processing lab work or may refer you to one of these providers.

EKGs and similar tests and imaging services received in a physician’s office may be billed by your physician as professional services or may be billed as facility services.

When does health insurance coverage begin?

Your coverage will begin on the first day of a pay period following two full pay periods of employment.

The two full pay period waiting period applies if you are a newly hired colleague or have transferred from a PRN position to a benefits eligible position.

Coverage for your dependents begins on the same day as your coverage as long as you have enrolled them for health insurance.